The Anxiety Game

It’s Rigged, so Let’s Change the Rules

By Reid Wilson

Therapists make clients feel safe and secure, right? Well, when it comes to treating anxiety, more clinicians are instructing clients to ramp their fears, while telling themselves how much they welcome the experience.

Anxiety and its next of kin, fear, are arguably the oldest, most basic human emotions, bequeathed to us by a vast history of prehominid ancestors. We owe our survival as Homo sapiens to these emotions, which were literally built into our nervous systems as an evolutionary hedge against extinction. Yet today, while still protecting us from genuine danger, they’ve morphed into a multitude of extraneous and dysfunctional afflictions—panic disorder, obsessive-compulsive disorder, phobias, and all-purpose generalized anxiety disorder (summoning up anxieties on any and all occasions)—the only effect of which seems to be to torment us pointlessly.

When I began my practice, psychotherapists still knew precious little about anxiety, even though it was probably the commonest form of suffering among the clients we saw. By and large, it was considered a symptom of some deeper psychodynamic process, and analysts helped clients find the deep-seated meaning behind their fears. The working Freudian hypothesis of agoraphobia in women, for instance, was that they withdrew to their homes out of an unconscious fear that they’d become prostitutes.

It wasn’t until the 1960s, when behavioral psychologist Joseph Wolpe’s experimental research perfected relaxation techniques and systematic desensitization, that anxiety began to be treated as a separate problem. To treat a fear of dogs, for instance, Wolpe taught the patient how to become deeply relaxed. He then introduced imagery that evoked a weak anxiety response, such as seeing a dog from a great distance and chained behind a fence. Relaxation procedures counteracted the anxiety produced by that image until it no longer distressed the patient. Wolpe would then introduce a slightly stronger anxiety-provoking image, such as being 20 feet away from a fenced-in dog, until it, too, ceased to arouse anxiety. Progressing up the hierarchy of fears about dogs led to recovery.

When it came to working with anxious clients, my own biggest asset was my experience, early in my career, of treating chronic pain patients in a hospital setting. I discovered that there were a number of similarities between the way people handle chronic pain and the way they handle anxiety symptoms. Those in chronic pain will anticipate their next pain episode with dread, so even though an episode might last only 10 minutes twice a day, it can dominate a pain patient’s waking hours.

Once I realized that I could substitute “panic attack” for “pain episode,” I began to get my bearings on treating the panic in agoraphobics, who’d started getting referred to me after a series of stories in the national media gave the condition a label for the first time. At first, I’d been hesitant to accept these referrals, but soon changed my mind. “Wait a minute,” I thought, “I know something about this.” Soon I’d cobbled together a treatment procedure.

I started by teaching agoraphobic clients formal relaxation, although I knew from my struggles with pain patients that, while relaxation could help some, it would never be enough. Additionally, I expected to use systematic desensitization, because it had worked well for the few clients I’d seen who’d had specific phobias. But with clients who feared panic, the method failed me. Since a panic attack arrives so unexpectedly, the client instantly becomes aroused to the highest degree and feels out of control. I couldn’t seem to undo that reflexive response by pairing relaxation with anxiety-provoking imagery of the event. Clients felt too scared to trust that these relaxation and desensitization skills would protect them.

I had to shift my thinking. I couldn’t help my clients undercut the intensity of their fear through some formal procedure in my office. Instead of progressing up a list of anxiety-provoking situations, I needed to focus on the on-off switch of panic. These clients either avoided their anxiety and felt comfortable or faced the threat and zoomed up to peak anxiety. I had to address the moment of panic. When you anticipate an anxiety attack, you desperately want something you can do that will bring immediate relief. I figured my primary strategy needed to focus on skills for responding to the actual feeling of panic.

I continued to teach formal relaxation, encouraging my agoraphobic clients to practice daily for a number of weeks. Then, instead of working only with imagery, we created and rehearsed a simple, structured, three-step response for panicky situations. As they approached a fearful situation, their first job was to counter their racing thoughts by mentally stepping back, accessing what I called “The Observer,” and objectively commenting on what they were noticing—what today we call “becoming mindful in the moment.” For instance, they might tell themselves, “We’re pulling into the parking lot, and I can feel my heart starting to race. I’m scared.”

Second, they were to shift their attention immediately to their well-rehearsed breathing skills. Focusing on the breathing had two functions: it reduced the chance that clients would start hyperventilating, which increased the symptoms they were trying to reduce, and it required conscious awareness. That helped draw their attention away from their fearful thoughts.

The third step was to subvocalize specific motivating messages that supported their goal of approaching the threatening situation. The most prominent were those that conveyed their intention to manage their distress instead of remove it. The common themes were “It’s OK to be anxious here” and “I can handle these feelings.” This step was no magic bullet, but it reversed the not-so-helpful tendency of desperately seeking comfort, which increases the distress because it’s an impossible goal in threatening moments. If clients could permit themselves to be somewhat anxious, they could learn to cope with their distress.

Once I’d developed this treatment approach, clients started getting better. After a while, I became a bit cocky about my clinical effectiveness. “No one else around here is doing this,” I thought to myself. “I’ve figured out something new!” So I decided to write a self-help book based on what I’d learned.

Then on one weekend in 1985, just as I completed the book, I got the proverbial wakeup call. I’d been looking through all my files to revel a little more in my successes and discovered that fully 40 percent of my clients had dropped out of therapy prematurely! None of them had said, “Dr. Wilson, this isn’t really working for me. I think I’m going to quit therapy with you.” They just didn’t make another appointment. Needless to say, none of this treatment failure had been showing up on my radar.

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Hello my name is Jason Linder. I'm finishing up my Master's in MFT at Alliant International University in Mexico City. I really enjoyed the article.

I'm wondering how applicable these principles of tough love and going toward anxiety are to Insomnia treatment. Part of me would deduce that the same concepts equally apply while another would say that they would all cause even worse sleeping. Sleep is different than panic attacks, phobias & OCD.

Thanks for this article. I really enjoyed the read. Great depiction of the chronology of the writer's developing thought process. There are possibilities raised for me that within the treatment of anxiety, perhaps where we should begin to focus to a greater degree is on client's discomfort with ambiguity and uncertainty. Perhaps the feeling of anxiety is enhanced by the unknown nature of the situation and outcome-so maybe we should also focus on the 'unknowingness' in tandem with habituating to the anxious feeling? Lots of food for thought here for me-thank you!

I'm trained and certified by the Department of Defense in both CPT (Cognitive Processing Therapy) and PE (Prolonged Exposure) therapy: The DoD's gold standards for treating and resolving PTSD (or in other words, Anxiety).

This approach closely aligns with the PE treatment model, but is better. I'm going to start applying the principles, and I expect to see positive outcomes.